Can frequent eye rubbing cause progressive retinal nerve fiber layer (RNFL) thinning, and how should it be managed?

Eye Rubbing and Progressive RNFL Thinning

Yes, frequent and chronic eye rubbing can cause progressive retinal nerve fiber layer (RNFL) thinning and glaucomatous optic neuropathy, even with normal intraocular pressure, and must be immediately stopped to prevent irreversible vision loss. 1

Evidence for Eye Rubbing as a Cause

The most compelling evidence comes from a documented case of a 52-year-old man who rubbed his eyes for more than 10 hours per day, resulting in:

• Bilateral advanced glaucomatous-like optic disc damage with consistently normal IOP (never exceeding 14 mmHg) 1
• Progressive visual deterioration over 4 years: right eye declined to 12/20 and left eye to counting fingers only 1
• Severe visual field compromise despite normal pressure readings throughout the observation period 1

This case demonstrates that recurrent and continuous eye rubbing can induce progressive optic neuropathy causing visual field damage similar to advanced glaucoma, independent of elevated IOP. 1

Mechanism and Clinical Significance

The mechanical trauma from chronic eye rubbing likely causes direct damage to the optic nerve head and RNFL through:

• Repeated mechanical stress and deformation of ocular structures 1
• Potential transient IOP spikes during rubbing episodes that are not captured during routine office measurements 1
• Direct compression and damage to the retinal ganglion cell axons 1

Management Algorithm

Immediate Actions:

• Complete cessation of eye rubbing is the single most critical intervention 1
• Identify and treat underlying causes of eye rubbing (allergies, dry eye, blepharitis, psychological factors) 1
• Document baseline RNFL thickness with OCT imaging to establish rate of progression 2

Monitoring Strategy:

• Serial OCT RNFL measurements every 3-4 months initially to detect ongoing progression 2
• Visual field testing to assess functional damage 2
• Document IOP at each visit, though it may remain normal 1

Common Pitfall:

Do not dismiss the diagnosis simply because IOP measurements are normal during office visits. The case report demonstrates that severe optic neuropathy can occur with consistently normal IOP when mechanical trauma from eye rubbing is the primary mechanism. 1

Prognosis Considerations:

If eye rubbing continues despite intervention, expect rapid and severe visual deterioration similar to advanced glaucoma, potentially leading to legal blindness. 1 The referenced patient lost functional vision in one eye (counting fingers only) within 4 years despite normal IOP. 1